03100054CITY OF CUPERTINO
BUILDING DIVISION PERMIT
corrrRAC"fOR�INFORMATION
BUILDING ADDRESS:
SWINERTON BUILDERS
PERMIT NO 03100054
.PER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY OL NO.
ARCHITECTIENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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I bereby affirm Wet 1 am licensed under provisions of Chapter 9 (commencing
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with Section 7010) of Division 3 ofine Business and Profeudum Code, and my lice.. is/
in full force and c0as.
EVISION-- TAIRS
License Claw Lm.g
Dors conrtaWr
NO MIT ISSUED/ ORIG. ${03020069
ARCHITECT'S DECLARATION
I undcnund my plans shall be ward as public mcmds
'
Licensed Professional
OWNER -BUILDER DECLARATION
I Wreby strum that I am exempt inner the Comraars License Law for the
following reason. (Sectian ]031.5, Business and Pmfuuiam Code: Any city or county
which requires a permit to construct, alar, improve. demolish, or repair any structure
prim m its issuance. also requires We applicant for such Permit to file a signed stamment
Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that W is licensed pursuant m the provisions of the
(commencing with Section 70110) of Division 3 of the Business and Professions Codm) or
that he is exempt Rumford and use basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by my applicant fm a permit Subjects the applicant the a civil penally of
not mom man firs hundred dollars (5500).
1, u owner of the property, m my employees with wagea a drelr sale compensation,
Required Inspections
will do the work and memuaua is net intended ora(fened fo... e(Sec. 7044, Business
and Professions Cads: The Coneamrl License Law does not apply W an Owner of
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papery, who bu llds m improvea the Iron. and who dans such work himself or through his
awn employees. provided that such improvements as not Inteeded OraErsed porins It.
hawewr. me building or improvement is mid within aro year of completion. the Owner.
Wilder will law due human of proving mat he did Out Wild or Improw fm purpose of
sae.).
❑ 1, as owner of the property, am exclusively contacting with licensed ontr.mr. 10
cautact she project (Sec. 7044, Business and Pro eWau Code:) The Contractors Li.
'
ceue Taw dans not apply m an owner of property who Wilda or improm menton,and ,
who Contracts for such prejects with a eomracar(0 licensed pursuant m me Contnaats
Case Isw.
am aempt under Sec, .B&PCfor mice moon
caner Dare
WORKER'S COMPENSA71ON DECLARATION
1 hereby affirm under penalty of perjury one of me following deri atious:
-
I ham and will maintain a Ccrtiftand Df Covent to ulf-insum for Workers Compere
anon, provided for by Section 3]00 a( Um liter Code. far me pcd'Ormeme of me
work for which this )amort is issued.
r
❑ 1 haw and will maintain Workers Compensation Iraaraa, a required by Section
37W.f me later Code. for Ne perfamnance Of ae work for which mu Permit is issued.
My Worker's Compensation Insurance Cartier and Paltry number am:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sada. nod not tecompmu d if ted permit la furore hundmddallars (51110)
or less.)
1 unify that In the performance of to work for which this permit u issued. l shall not
employ any Aman in any manner an as to become subject to 1W Workers Compensation
Law. of Califomle. Dem
Applicant
NOTICE TO APPLICANT. IL after making this Ccnificate of 9scmption, you should
Wcome subject W that Worker] Compensation provisions of the later Cad, you must
faMwith comply wish such provisions or this Permit shall he deemed ranked.
CONSTRUCTION LFig01NGAGENCV
1 W affirm ren mem ice lending agency for she perfurmance of
a
r w rd (Sec.3
the work for which this )snort u issued (Sec. 7097. CO, CJ
Lenders Name
Lenders Addmu
I unify that 1 haw mad this application ad stars that the show information is
Correa. l agree to comply with all city and county Ordinances and sure lawn misting a
building construction. and hereby Nuou re reprucnutivaa of this city to enter upon me
l abovcmcntimed pmNrty for impaction purposes.
(Wc) agree W saw, indemnify and lamp harmless the City of Cupmino against
j Ilabilitiesjudgmtnu, casts and eapensrs which may in my way accrue against said City
in consegance of she granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT-
Issued by; Dat
SOURCE REGULATIONS,
Re -roofs
Signature of ApplicanUConRDO Dete
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will that applicant or (uwm building occupant nom m handle hnudous material
dented by the Cupertino Municipal Code, Chapter 9.13. and the HCaIsh and Safety
mm, creeds. 2svz(.r
All roofs shall be inspected prior to any roofing material beteg installed.
nyc ONO
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant Or future building Occupant use equipment or devices which
emit hersedous air contaminants u defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yca C] No
1 have mad the harardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Cade, Sections 25505,25573 and 25534, 1 understand that trust Wilding
dais not Connolly hew a tenak Net It is my responsibility m nonny me occupant of the
requirements which must W met prior to iaummt of a Ccnificate of OCcuPanry
Signature Of Applicant Date
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All roof coverings to he Class "B" or better
Owner ar.amorized. a,